IN THE CASE OF: 

		BOARD DATE: 4 October 2023

		DOCKET NUMBER: AR20230003929


APPLICANT REQUESTS: correction of Standard Form (SF) 600 (Chronological Record 
of Medical Care) to show he experience pain in his left wrist vice his right wrist.

APPLICANT'S SUPPORTING DOCUMENT(S) CONSIDERED BY THE BOARD:

*	DD Form 149 (Application for Correction of Military Record)
*	SF 600, 10 July 1986
*	DD Form 689 (Sick Call Slip)

FACTS:

1.  The applicant did not file within the 3-year time frame provided in Title 10, U.S. 
Code, section 1552(b); however, the Army Board for Correction of Military Records 
(ABCMR) conducted a substantive review of this case and determined it is in the 
interest of justice to excuse the applicant's failure to timely file.

2.  The applicant states on 10 July 1986, he went to sick call for his left wrist as listed on 
DD Form 689 (Sick Call Slip). On the Chronological Record (SF 600) it is listed as his 
right wrist. Both forms should indicate his left wrist. He is having problems with this 
wrist; he needs to do a claim. The wrist was hurt in the line of duty.  

3.  The applicant served honorably in the Regular Army from 15 August 1968 to 
22 July 1970. 

4.  On 6 July 1972, the applicant enlisted in the Army National Guard of the State of 
Louisiana and as a Reserve of the Army.

5.  The applicant was activated is support of Operations Desert Shield and Storm, 
serving honorably on active duty from 30 November 1990 to 20 April 1991.  

6.  A Statement of Medical Examination and Duty Status, dated 1 August 1998, shows 
approval for a line of duty package for exacerbation of chronic low back pain.

7.  On 1 January 2001, the applicant was discharged and placed on the Retired 
Reserve list awaiting pay at age 60.  

8.  The applicant’s available record is void of a line of duty determination for his wrist 
injury. His Army National Guard Retirement Points History Statement prepared on 
25 November 2003 shows he was in an active drilling status for the anniversary year 
15 August 1985 to 14 August 1986, earning 26 active-duty points.  

9.  The applicant provided an Individual Sick Slip, dated 10 July 1986, showing he was 
seen for pain in left wrist in the line of duty. 

10.  He also provided a Chronological Record of Medical Care, dated 10 July 1986, 
showing he was seen for pain in right wrist. It states pain started a few days ago, sharp 
pain has stayed, hurst when driving. Does seem to be a little something around the 
wrist, might be a light sprain. Wrapped with an ace wrap to be sure just in case, give 
Tylenol for pain. 

11.  MEDICAL REVIEW:

    a.  The Army Review Boards Agency (ARBA) Medical Advisor was asked to review 
this case. Documentation reviewed included the applicant’s ABCMR application and 
accompanying documentation, the military electronic medical record (AHLTA), the VA 
electronic medical record (JLV), the electronic Physical Evaluation Board (ePEB), the 
Medical Electronic Data Care History and Readiness Tracking (MEDCHART) 
application, and the Interactive Personnel Electronic Records Management System 
(iPERMS).  The ARBA Medical Advisor made the following findings and 
recommendations:   
    b.  The applicant is applying to the ABCMR requesting a change in a medical record 
to assist with the filing of a claim with the Veterans Benefits Administration (VBA). He 
states:
“10 July 1986, I went to sick call for my left wrist as listed on DD689 Sick Call 
Slip. On the Chronological Record (Standard Form 600-106-01) its listed as my 
right wrist.  Both forms should indicate my left wrist.  I am having problem with 
this wrist. The wrist was hurt in line of duty ... My left wrist is giving me problems, 
I need to do a claim.”
    c.  The Record of Proceedings outlines the applicant’s military service and the 
circumstances of the case.  His Report of Separation and Record of Service (NGB Form 
22) shows he entered the Army National Guard on 6 July 1972 and was honorably 
discharged from the Louisianan Army National Guard (LAARNG) on 1 January 2001 
under the authority provided in paragraph 8-27u of NGR 600-200, Enlisted Personnel 
Management: Discharge and transfer to the Retired Reserve for soldiers are not yet age 
60.  
    d.  Because of the period of service under consideration, there are no encounters in 
AHLTA.
    e.  Supporting documentation contains the DD form 689 showing the pain was in his 
left wrist and the SF 600 showing the provider wrote right wrist.  
    f.  The Privacy Rule, part of the Health Insurance Portability and Accountability Act 
(HIPAA), gives patients, with few exceptions, the right to inspect, review, and receive a 
copy of their medical records and billing records that are held by health plans and health 
care providers covered by the Privacy Rule.  This includes the ability to request 
corrections or amendments to these records when a patient believes information in their 
medical or billing record is incorrect.    
    g.  The Privacy Rule provides individuals with this right to have their protected health 
information (PHI) amended in a manner that is fully consistent with the Correction 
Principle in the Privacy and Security Framework (See 45 C.F.R. § 164.526).  The health 
care provider or health plan must respond to this request, and if it created the 
information, it must amend inaccurate or incomplete information.   If the provider or plan 
does not agree to the request, the patient has the right to submit a statement of 
disagreement that the provider or plan must add to the record.
    h.  Review of his records in JLV show he has three service-connected disabilities, 
none of which are related to an upper extremity.
    i.  It is the opinion of the ARBA medical advisor this error would not prevent the 
applicant from filing a claim with VBA.  If the applicant desires to correct the error, it is 
recommended he utilize the process provided by HIPAA.  


BOARD DISCUSSION:

After reviewing the application, all supporting documents, and the evidence found within 
the military record, the Board found that relief was not warranted. The Board carefully 
considered the applicant's record of service, documents submitted in support of the 
petition and executed a comprehensive and standard review based on law, policy and 
regulations. Upon review of the applicant’s petition, available military records and 
medical review, the Board concurred with the advising official finding the error would not 
prevent the applicant from filing a claim with VBA.  If the applicant desires to correct the 
error, it is recommended he utilize the process provided by HIPAA. The opine noted, the 
applicant record shows he has three service-connected disabilities, none of which are 
related to an upper extremity. The Board determined based on the medical opine, there 
is insufficient evidence that warrants correction of Standard Form (SF) 600 
(Chronological Record of Medical Care) to show he experience pain in his left wrist vice 
his right wrist. The Board agreed relief is not warranted as noted by the medial opine 
who provided that the applicant should us the Health Insurance Portability and 
Accountability Act (HIPAA) for correction.


BOARD VOTE:

Mbr 1	Mbr 2	Mbr 3

:	:	:	GRANT FULL RELIEF

:	:	:	GRANT PARTIAL RELIEF

:	:	:	GRANT FORMAL HEARING

:X	:X	:X	DENY APPLICATION


BOARD DETERMINATION/RECOMMENDATION:

The evidence presented does not demonstrate the existence of a probable error or 
injustice.  Therefore, the Board determined the overall merits of this case are insufficient 
as a basis for correction of the records of the individual concerned.


	 
I certify that herein is recorded the true and complete record of the proceedings of the 
Army Board for Correction of Military Records in this case.


REFERENCES:

1.  Title 10, U.S. Code, section 1552(b), provides that applications for correction of 
military records must be filed within 3 years after discovery of the alleged error or 
injustice. This provision of law also allows the ABCMR to excuse an applicant's failure to 
timely file within the 3-year statute of limitations if the ABCMR determines it would be in 
the interest of justice to do so.

2.  Army Regulation 40-66 (Medical Record Administration and Healthcare 
Documentation) prescribes policies for preparing and using medical reports and records 
for Soldiers receiving medical treatment or evaluation in an Army military treatment 
facility.

	 a.  Chapter 3 (Preparation of Medical Records) states that unless authorized by this 
regulation, only documents prepared by authorized U.S. Army Medical Department 
(AMEDD) personnel will be filed in Army medical records. This restriction does not 
prohibit the use of other documents created by attending physicians and dentists 
outside AMEDD (Navy, Air Force, civilian, and so forth) or the filing of other documents 
as summaries or brief extracts. If such documents are filed, their source and the 
physician or dentist under whom they were prepared must be identified.

	b.  Medical record entries will be made in all inpatient, outpatient, service treatment, 
dental, Army Substance Abuse Program, and occupational health records by the 
healthcare provider who observes, treats, or cares for the patient at the time of 
observation, treatment or care. No healthcare practitioner is permitted to complete the 
documentation for a medical record on a patient unfamiliar to him or her. In unusual 
extenuating circumstances (for example, death of a provider), local policy will ensure 
that all means have been exhausted to complete the record.

3.  Section 1556 of Title 10, USC, requires the Secretary of the Army to ensure that an 
applicant seeking corrective action by the Army Review Boards Agency (ARBA) be 
provided with a copy of any correspondence and communications (including summaries 
of verbal communications) to or from the Agency with anyone outside the Agency that 
directly pertains to or has material effect on the applicant's case, except as authorized 
by statute. ARBA medical advisory opinions and reviews are authored by ARBA civilian 
and military medical and behavioral health professionals and are therefore internal 
agency work product. Accordingly, ARBA does not routinely provide copies of ARBA 
Medical Office recommendations, opinions (including advisory opinions), and reviews to 
Army Board for Correction of Military Records applicants (and/or their counsel) prior to 
adjudication.
//NOTHING FOLLOWS//
ABCMR Record of Proceedings (cont)	AR20230003929


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ARMY BOARD FOR CORRECTION OF MILITARY RECORDS

RECORD OF PROCEEDINGS


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